EMS Vaccine Administration Warrants a National Standard

U.S. Army 1st Lt. Michelle Torres from Madigan Army Medical Center trains Army combat medics with the 4th Infantry Division on a variety of syringes at the Community Vaccination Center at California State University Los Angeles, March 15, 2021.
U.S. Army photo by Pfc. Garrison Waites/5th Mobile Public Affairs Detachment

Establishing a national standard for EMS vaccine administration can improve healthcare resource utilization.

Access to any of the authorized COVID-19 vaccines has now benefited millions of adolescents and adults across the U.S. population. Unlike other vaccines that are administered in accordance with Centers for Disease Control and Prevention (CDC) immunization schedules, the COVID-19 vaccine has demanded an unprecedented scaling of resources for administration and patient management beyond the traditional primary care or hospital environment. This effort has largely fallen on the shoulders of licensed clinicians who are trained to administer the vaccine. Several states, in response to resource demands, have issued temporary orders that grant authorization of administration through prehospital providers and state-certified emergency medical services (EMS) personnel.1 EMS and fire services across the country have helped to alleviate the burden on COVID-19 vaccination on the nation’s healthcare providers, thus facilitating the continuation of care in their communities. EMS has played a significant role in optimizing their field resources and training to facilitate vaccination and local community centers and other designated administration sites.

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Yet in times of non-declared crises, such authorizations can vary among states and are applied to different levels of EMS providers inconsistently.2 The lack of a national standard thus far has the potential to lead to confusion and barriers for efficient vaccine administration. The success of such state-issued administration orders for EMS-fire services during the COVID-19 epidemic illustrates the practical, clinical, economic and societal value of establishing complementary vaccine administration efforts by prehospital providers. We propose that developing a national standard for certification for a vaccine administration protocol across first responders benefits the healthcare system while strengthening the effectiveness of prehospital care.

Lessons from the Current Climate

More than 330 million COVID-19 vaccinations have been administered to date in the U.S., with more than half of these being patients who have received at least one of two required doses from the Pfizer and Moderna vaccines.3 This statistic represents a relative change of 33% from vaccinations administered in December 2020. Although the U.S. outpaces the global average in the COVID-19 vaccination rate, it nevertheless lags behind projections for an adequately vaccinated population. In Massachusetts alone, where we reside and work, 62% of the state’s population has been recorded as being fully vaccinated.4 Second to Vermont only, the success in Massachusetts can be attributed to a state protocol that extends vaccination authorization to advanced EMTs.

The need for preparedness in response to the next national crisis cannot be overstated. Specifically, the creation of a large pool of healthcare providers with a vaccination skill set on which to draw requires that the “demand” for this service must be established. Doing so not only will streamline the process of vaccine administration but also alleviate much of the burden on smaller communities that may not have resources to spare. In response to the shortage of vaccine administrators during the mass vaccination effort of 2021, the paradigm intra-nationally appears to be the ad hoc solution of drawing personnel from various medical and scientific backgrounds to act as vaccine administrators. While effective, this practice has highlighted shortcomings of the healthcare and emergency preparedness/disaster management systems currently in place, most notably the lack of the development of a specific framework for such an operation.

A Burden on the Healthcare System

The demand of the real-time state-phased COVID-19 vaccination roll-out on healthcare organizations required hasty redeployment of its employees, facilities, and resources (including financial support). Healthcare organizations were challenged to expand capacity for operational matrices not embodied in standards of business and to ramp up innovative models.

In order to respond to the ever-changing climate of COVID-19 and to ramp up vaccination administration, independent administrational infrastructures were established, and staffing of those teams was necessary. However, all healthcare systems were forced to quickly respond operationally without the luxury of an organizational build or having the advantage of the guidance of preexisting models. Organizations were burdened with meeting patient demand as their hospitals became host sites for vaccine administration. To meet this need, the use of vendor restructured and newly developed workflows were vital in creating appointment slots and supply data.5

All, but in particular, smaller services (e.g., private practices) were burdened with staffing challenges to meet the mass demand for scheduling, coordinating, and storage of vaccinations and materials. Technological infrastructure was bombarded as the public scrambled to communicate and schedule their vaccinations. The demands further necessitated creation and streamlining of separate phone lines and communication technologies (automated responses, text and email alerts, Web-RTC) along with caller scripts.6 Certain adherence measures, such as tracking, became a logistical, and at times insurmountable, hurdle for the small and the mighty. For example, a seemingly small fix was achieved when “non-patients” seeking vaccinations did not have system registrations, which challenged the already taxed institution. One invaluable solution implemented by many hospital systems was to provide EHR-scheduled second vaccination appointments which required IT and EHR collaboration to create a workflow and associated training.7

Depending on which vaccination was supplied to the site, different challenges arose. The J&J vaccine required only one dose and was the easiest to store (refrigeration) and dispense, lending an advantage to those residing in rural and remote settings.8Vaccination shortages not only curtailed efforts but further added to the demand burden of supplies ranging from PPE to freezers.9Other challenges for systems arose, such as vaccination disposal, especially given the limited supply and no-show consumers. The media depicted stories of vaccination workers seeking random individuals to vaccinate and avoid waste.10 These accounts demonstrate the advantage of a mobile model where direct delivery to communities was provided, rather than scheduling the public to present at a random state-designated site and in doing so, burdening facilities and personnel to meet the influx of non-traditional business needs.

Quality and risk issues abounded as well during the vaccine rollout. One such case has been the use of vaccine overfill (after cleared for emergency authorization use by Food and Drug Administration),which requires specific syringe gauge sizes and training.11Some advocacy groups, such as the Public Health Foundation, have proposed quality improvement initiatives that integrate a “process decision process chart” (PDPC) to help address waste and foolproof drug distribution.12 These are valuable lessons that can further inform a national standard for EMS vaccine administration protocol.

Healthcare workers – clinicians and non-clinicians alike from every sector – likewise found themselves redeployed, testing their capacity, bandwidth, and expertise while their home teams were burdened with carrying the reduced workforce burden. Clinicians needed to be scaled to meet adverse events and special population needs.13 Pharmacists too were engaged in the clinical care realm across organizations in greater capacities than ever before to meet developing and performing supply-chain duties.14 Clinical and administrative collaboration between EMS and health system providers is central to safe and effective prehospital/emergency care and has been leveraged significantly throughout the pandemic. Some examples of the collaboration are: the COVID-19 response protocols redirecting EMS assisted patients to alternative sites served to reduce the burden on hospitals, rapid COVID-19 field tests, and granting EMS-providers hospital access to perform advanced life support (ALS) skills care.15 A shared COVID-19 vaccination model in partnership with EMS and hospital providers reinforces the rationale for a national standard.

The healthcare organization “last-mile efficiency” of the vaccination rollout has been a critical component to striving for herd immunity. Yet, the expectation that the public will present, without barriers, to sites has been unrealistic. This, in combination with health inequities and disparities in vaccine disbursement, only furthers the importance of utilizing trained, competent, and respected EMS providers in the communities to administer vaccinations. The value of an EMS-led vaccination rollout can unburden health systems and their employees while maintaining cohesiveness across agencies delivering a government-led initiative.

Proposal for a National Competency Standard

The National Registry of Emergency Medical Technicians (NREMT) is the organization responsible for certifying prehospital healthcare providers to four incremental levels of competency and scope of practice. These certification levels increase in skillset and responsibility from the emergency-medical responder through the paramedic levels. NREMT certification is recognized in all 50 states, and in 46 states such certification is a prerequisite to qualify for a state license to practice.16 Certification is awarded to an individual after he or she successfully completes an accredited training program and subsequently passes both cognitive and psycho-motor examinations.

Completion of both examinations assures that the provider has met the requisites for proper understanding of defined clinical skills, as well as the physical ability to exercise those skills when indicated. Once certified nationally and licensed at the state level, the prehospital provider’s scope of practice is further determined by the individual state’s Office of Emergency Medical Services (or similar governing agency) as well as regional or local medical directors. The national curriculum as it exists in 2021 allows paramedic-level providers to administer a myriad of intramuscular injections (IM) using both auto-injector devices and syringe-and-vial methods. Providers practicing at the EMT-Basic (EMT-B) level, however, are relegated to using pre-measured dose/auto-injector devices, such as the Epi-Pen (pre-filled epinephrine syringe).

During the past few years, notable examples of state protocols have emerged allowing an EMT-B to administer IM injections with the syringe-and-vial method after receiving additional training. Most notably is the epinephrine delivery system, known as “Check and Inject,” where an EMT-B will draw medication from a vial and administer it to the patient via syringe. This protocol has been established in New York, Connecticut, Massachusetts and Washington. A precedent thus exists to support competency using a vial and delivery via syringe within an EMT-B psycho-motor ability.17,18,19,20,21

With the exception of the relatively new “community paramedicine” concept, vaccine administration has not been a significant part of emergency medical treatment protocols. This is beginning to change, though, with multiple states in 2020 and 2021 issuing “special protocols” (or similar) allowing EMT-B through paramedic providers to administer COVID-19 vaccines in accordance with public health orders.22,23 The National Highway Traffic Safety Administration, Office of Emergency Medical Services (NHTSA-OEMS) has even released the “Just in Time” training resources, specifically aimed at familiarizing EMT-Bs with vaccine administration.24

If the NREMT (or an applicable governing agency) first acknowledges that EMT-B providers and above are fully capable of vaccine administration, as well as incorporating administration technique into the initial curriculum and bi-annual refresher training, the pool of eligible vaccine administrators is bound to expand and become available upon request/activation of special protocols and public health demand in the future. This will decrease the draw of resources on the health system in place, and it will help sustain the value of allied health providers in their current roles.25

Conclusion

Given the limited resources of nurses and other healthcare system providers, the burden of administering COVID-19 vaccines can be equally distributed and shared by qualified prehospital providers. Implementing vaccine administration within national EMS certification helps to expand the scope of practice among first responders, from EMT-B through paramedic levels. Such reform – to standardize a national competency – can advance statewide protocols that integrate training and recertification efforts to ensure safe and efficient response to declared emergencies in the future.

References

1. National Association of State EMS Officials. (2020). Emergency medical services personnel as vaccinators. Retrieved August 16, 2021 from https://nasemso.org/wp-content/uploads/COVID-Vaccination-Report.pdf

2. National Association of State EMS Officials. (2020). Emergency medical services personnel as vaccinators. Retrieved August 16, 2021 from https://nasemso.org/wp-content/uploads/COVID-Vaccination-Report.pdf

3. Our World in Data. (n.d.). Retrieved August 16, 2021 from https://ourworldindata.org/covid-vaccinations

4. Mayo Clinic. (n.d.). Retrieved August 16, 2021 https://www.mayoclinic.org/coronavirus-covid-19/vaccine-tracker

5. Jercich K. (2021). CIOs weigh in on the most useful tools for the COVID-19 vaccine rollout. Retrieved May 6, 2021 from https://www.healthcareitnews.com/news/cios-weigh-most-useful-tools-covid-19-vaccine-rollout

6. Masson G. (2021). How 2 health systems made their COVID-19 vaccine rollout as efficient as possible. Retrieved May 6, 2021 from https://www.beckershospitalreview.com/public-health/how-2-health-systems-made-their-covid-19-vaccine-rollout-as-efficient-as-possible.html

7. Masson G. (2021). How 2 health systems made their COVID-19 vaccine rollout as efficient as possible. Retrieved May 6, 2021 from https://www.beckershospitalreview.com/public-health/how-2-health-systems-made-their-covid-19-vaccine-rollout-as-efficient-as-possible.html

8. Goldhill O. (2020). Rural hospitals can’t afford freezers to store a Covid-19 vaccine. Retrieved May 6, 2021 from https://www.statnews.com/2020/11/11/rural-hospitals-cant-afford-freezers-to-store-pfizer-covid19-vaccine/

9. Shah B. (2021). One year later: Key issues impacting health system pharmacies during the COVID-19 vaccine rollout. Retrieved May 6, 2021 from  https://www.pharmacytimes.com/view/one-year-later-key-issues-impacting-health-system-pharmacies-during-the-covid-19-vaccine-rollout.

10. Levenson M. (2021). Health workers, stuck in the snow, administer coronavirus vaccine to stranded drivers. Retrieved May 6, 2021 from https://www.nytimes.com/2021/01/28/us/oregon-vaccine-stuck-in-the-snow-drivers.html

11. Shah B. (2021). One year later: Key issues impacting health system pharmacies during the COVID-19 vaccine rollout. Retrieved May 6, 2021 from  https://www.pharmacytimes.com/view/one-year-later-key-issues-impacting-health-system-pharmacies-during-the-covid-19-vaccine-rollout.

12. Bialek R, et al. (2021). Reducing COVID-19 vaccine waste.” Retrieved May 6, 2021 from  http://www.phf.org/resourcestools/Pages/Reducing_COVID-19_Vaccine_Waste.aspx

13. Courtney LA, Reilly K. (2020). COVID-19 vaccine administration training. Retrieved August 16, 2021 Massachusetts Department of Public Health, Massachusetts Department of Public Health, https://www.mass.gov/doc/covid-19-vaccine-administration-training/download.

14. Brailo A, et al. (2021). How health systems are navigating rollout of the J&J COVID-19 vaccine. Retrieved May 6, 2021 from https://www.premierinc.com/newsroom/blog/how-health-systems-are-navigating-rollout-of-the-j-j-covid-19-vaccine

15. Wenz K. (2021). What did 2020 teach the EMS Community? Retrieved May 21, 2021 from  https://www.pocketprep.com/posts/what-did-2020-teach-the-ems-community/

16. National Registry of Emergency Medical Technicians. (n.d.). Retrieved August 16, 2021 from https://www.nremt.org/about/about-us

17. New York State Department of Health. (n.d.). Retrieved August 16, 2021 from https://www.health.ny.gov/professionals/ems/policy/17-06.htm

18. New York State Department of Health. (n.d.). Retrieved August 16, 2021 from https://www.health.ny.gov/professionals/ems/policy/17-06.htm

19. Counts CR. (2018). Research analysis: Check and inject program is safe and cost effective. Retrieved August 16, 2021 from https://www.ems1.com/research/articles/research-analysis-check-and-inject-program-is-safe-and-cost-effective-ULVuIT0zR3a0D0SF/

20. https://portal.ct.gov/-/media/Departments-and-Agencies/DPH/dph/ems/pdf/Training/EMT-IM-EPI-Education-Policy-FINAL-2019_02_07.pdf

21. State of Connecticut Education and Training Committee. (2019). Intra-muscular administration of epinephrine. Retrieved August 16, 2021 from https://www.mass.gov/doc/emergency-medical-services-out-of-hospital-treatment-protocols-version-20212-effective-june-15-2021/download

22. Massachusetts Department of Public Health, Office of Emergency Medical Services. (2020). EMS statewide treatment protocols. Retrieved August 16, 2021 from https://www.mass.gov/doc/special-protocol-for-ems-personnel-flu-vaccination-under-commissioners-order-december-18-2020/download

23. State of California – Health and Human Services Agency. (2021). Federal EMT COVID-19 vaccinations guidance. Retrieved August 16, 2021 from https://emsa.ca.gov/wp-content/uploads/sites/71/2021/03/EMT-COVID-Vaccination-Memo-Federal-Vaccination-Guidance.pdf

24. NHTSA Office of EMS. (2021). Just in time training resources for EMT SARS-CoV-2 vaccinators. Retrieved August 16, 2021 from https://www.ems.gov/pdf/Just_In_Time_Training_EMT_Vaccination_Programs.pdf

25. The White House. (2021). Fact sheet: President Biden expands efforts to recruit more vaccinators. Retrieved August 16, 2021 from https://www.whitehouse.gov/briefing-room/statements-releases/2021/03/12/fact-sheet-president-biden-expands-efforts-to-recruit-more-vaccinators/

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